Understanding Pediatric Echocardiograms¶

Learning Objectives¶

Core Knowledge & Clinical Reasoning¶

[ ] Identify indications for ordering an echocardiogram in children
[ ] Interpret basic echocardiographic findings on reports (normal vs abnormal)
[ ] Understand Z-scores and why they matter more than absolute measurements
[ ] Recognize findings that require urgent cardiology consultation

Management Decisions¶

[ ] Determine when a patient needs an echo vs clinical observation
[ ] Know when to call cardiology urgently based on echo findings
[ ] Understand typical follow-up intervals for common findings

Communication & Counseling¶

[ ] Explain to families what an echo shows and what it doesn't
[ ] Discuss significance of "small hole" or "leaky valve" findings
[ ] Address family concerns about findings and their implications

Systems-Based Practice¶

[ ] Order appropriate type of echo (TTE, stress, TEE)
[ ] Coordinate follow-up based on findings

Key Guidelines¶

2024 ASE Guidelines for Comprehensive Pediatric TTE J Am Soc Echocardiogr. 2024;37:119-170

When to Order an Echocardiogram¶

Definite Indications¶

Finding	Why Echo Needed
Murmur + symptoms	Rule out structural disease
Abnormal pulses	Coarctation, aortic stenosis
Cyanosis	CHD evaluation
Failed CCHD screen	Confirm/exclude CHD
Syncope + exertion	HCM, coronary anomalies
Known CHD follow-up	Monitor lesion progression
Kawasaki disease	Coronary artery assessment
Chest pain + abnormal ECG	Myocarditis, cardiomyopathy
Family history sudden death	Screen for HCM, ARVC

Usually NOT Needed¶

Finding	Why Echo Usually Unnecessary
Innocent murmur (classic features)	Clinical diagnosis sufficient
Chest pain, normal exam/ECG	Rarely cardiac in children
Isolated palpitations, normal ECG	Start with Holter
Asymptomatic athlete clearance	ECG more appropriate screen

Understanding the Echo Report¶

Structure Assessment¶

What they measure: - Chamber sizes (left/right atrium and ventricle) - Wall thickness - Valve structure

What Z-scores mean: - Z-score = how many standard deviations from normal for body size - Normal: -2 to +2 - Borderline: 2.0 to 2.5 - Abnormal: >2.5 or <-2.5

Pearl: Z-scores matter more than absolute numbers

A 4-year-old and 14-year-old cannot have the same "normal" LV size. Always look at Z-scores.

Function Assessment¶

Parameter	Normal	Concerning
LV Ejection Fraction (EF)	55-70%	<50%
LV Shortening Fraction (SF)	28-40%	<25%
RV Function (TAPSE)	Age-dependent	<2 SD for age

Valve Assessment¶

Regurgitation grading: - Trivial/trace: Usually physiologic, no concern - Mild: Usually tolerated, monitor - Moderate: May need intervention eventually - Severe: Usually requires treatment

Stenosis (gradients): - Mild: Peak gradient <25 mmHg - Moderate: 25-50 mmHg - Severe: >50 mmHg (valvar AS) or >40 mmHg (CoA)

Common Echo Findings Explained¶

"Small VSD"¶

Tiny muscular VSDs are common in newborns
Most close spontaneously (especially <3mm)
Usually no treatment, no restrictions
Tell families: "A tiny hole that will likely close on its own"

"Trivial TR/MR/PR"¶

Trace regurgitation is NORMAL
Found in most normal hearts
No clinical significance
Tell families: "Normal finding, not a problem"

"Mildly dilated LV"¶

Z-score 2.0-2.5
May be athletic heart, volume loading, or early cardiomyopathy
Needs clinical correlation
Follow-up: Repeat echo in 3-6 months if unexplained

"Patent Foramen Ovale (PFO)"¶

Present in ~25% of population
Usually incidental finding
No treatment, no restrictions
Tell families: "Normal variant, everyone has this before birth"

When to Call Cardiology Urgently¶

Call Cardiology Immediately

EF <40% or significant decline from prior
Large pericardial effusion with tamponade physiology
Severe valve stenosis (especially aortic)
Coronary artery abnormality (aneurysm, anomalous origin)
New severe ventricular dysfunction
Evidence of endocarditis

Z-Score Quick Reference¶

Where to Look Up Z-Scores¶

parameterz.com - Multiple calculators
zscore.chboston.org - Boston Children's calculator

Which System for What¶

Structure	Use This System
Coronary arteries	PHN (Pediatric Heart Network)
Aortic root	Multiple valid options
LV dimensions	Boston, Detroit

Board Pearls¶

Pearl: Z-scores >2.5 are significant

This is roughly 2 standard deviations above mean - only ~1% of normal population

Pearl: Kawasaki coronary assessment requires PHN Z-scores

Absolute measurements not valid - must calculate Z-score for body size

Pearl: EF <55% in a child is abnormal

Unlike adults, children should have robust LV function

Self-Assessment¶

Q1: A 4-week-old has a grade 2/6 murmur at LUSB. Echo shows small restrictive muscular VSD with left-to-right shunt, normal LV size and function. What do you tell the parents?

Answer

**Answer**: Reassure that this is a small hole between the heart chambers that will likely close on its own. No restrictions, no treatment needed. Follow-up echo in 6-12 months. **Rationale**: Small muscular VSDs are common, usually close spontaneously, and rarely cause problems. The normal LV size confirms this is hemodynamically insignificant.

Q2: An 8-year-old with Kawasaki disease (day 10) has echo showing RCA diameter 3.5mm. BSA 0.9 m2. Is this concerning?